Natalia Litvinova

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The All-Russian seminar "Organizational and methodological issues for the primary accreditation of graduates - 2017" was held on February 16 at the First Moscow State Medical University. THEM. Sechenov.

An intensive training course consisting of two blocks - theoretical and practical - was offered to the chairmen of the accreditation commissions - representatives of non-profit professional organizations that are to conduct a large-scale campaign for the primary accreditation of medical graduates in the summer of 2017.

The organizers of the seminar are the Ministry of Health of Russia, the Union of the Medical Community "National Medical Chamber" and the Methodological Center for Accreditation of Specialists.

The moderator of the seminar was the Vice-Rector for Research and Professional Education of the First Moscow State Medical University. THEM. Sechenov Sergei Shevchenko. Opening the seminar, he conveyed the wishes of successful and fruitful work on behalf of the Rector of the University, Academician of the Russian Academy of Sciences Petr Glybochko.

Leonid Roshal, President of the National Medical Chamber, addressed the seminar participants with a call to create an effective structure for primary accreditation of graduates, laying the foundations for successful work for many years to come from the very beginning. He noted that along with the development of professional standards, primary accreditation is “a specific work that has been transferred by the Russian Ministry of Health to the National Medical Chamber, a state-public form of educational activity management.”

Director of the Department of Medical Education and Personnel Policy in Health Care of the Ministry of Health of Russia Tatyana Semenova explained that the seminar was held in the reference Methodological Center for Accreditation of Specialists, created on the basis of the First Moscow State Medical University. THEM. Sechenov. And ideally, it is in such conditions that accreditation should take place. She also spoke about the legislative norms that regulate the transition to the accreditation procedure for medical and pharmaceutical specialists. Accreditation is introduced in stages, from January 1, 2016 to December 31, 2025.

Detailed explanations about who will be accredited, how the commission is formed, what documents are required for the admission and assessment of a specialist are contained in the order of the Ministry of Health of the Russian Federation dated June 2, 2016 No. 334n. Tatyana Semenova explained the need for accreditation as a "global era of change." New technologies, Federal State Educational Standards and professional standards are being introduced, and the requirements for quality management of medical care are being unified. In general, specialist accreditation is a special form of examination, consisting of several successive stages.

Director of the Methodological Center for Accreditation of Specialists Zhanna Sizova made a presentation and explained in detail the features of each stage. Each stage is an independent exam, which gives the right to admission to the next stage. Primary and primary specialized accreditation include: testing, assessment of practical skills (skills) in simulated conditions, solving situational problems.

Each stage is evaluated by the accreditation commission in the format passed/failed. The stages of testing, assessment of practical skills are considered passed if at least seventy percent of the answers, practical actions are correct. The stage of solving situational problems is considered passed if at least ten questions out of fifteen possible are answered correctly.

Graduates of universities who have passed accreditation can start working in the primary link - district therapists in polyclinics. Residency graduates will face a more difficult exam - primary specialized accreditation, which gives them the right to enter specialized medical activities. Three attempts were given to pass each stage of accreditation.

Zhanna Sizova spoke in detail about all the intricacies of primary accreditation and suggested that the participants of the seminar proceed to the second - practical block of the seminar - a demonstration of the procedure for primary accreditation in the specialty "General Medicine" and get acquainted with the stations of the Objective Structured Clinical Examination (OSKE) to test the development of professional competencies of graduates. Stations for cardiopulmonary resuscitation, emergency and emergency medical care, physical examination of the patient, medical examination were presented to test competencies that correspond to the labor functions of a district general practitioner in accordance with the professional standard.

The practical block aroused great interest among the participants of the seminar. In general, the seminar held in full provided information on changes in the procedure for admission to professional activities of graduates of Russian medical universities and actually became the start of the primary accreditation of graduates of medical universities in 2017.

In 2017, more than 37,000 graduates of medical universities in eight specialties will undergo primary accreditation:

Natalia Litvinova

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Here, perhaps, is the question that should be asked by those who this year got sick of their own or happily avoided infection.

The fact is that 2016 and 2017 are a time of great change for medical students, and therefore for all of us. Since September of this year, internships for dentists and pharmacists have been canceled, and since September 2017 - for pediatricians and therapists (Federal Law of November 21, 2011 No. 323 "On the fundamentals of protecting the health of citizens in the Russian Federation").

An internship is twelve months of practical training. Previously, without completing a one-year course of postgraduate education, specialists were not allowed into practical healthcare. Now, to go to work in a polyclinic, it will be enough to get a diploma of graduation from a university.

Only if a young doctor dreams of becoming a surgeon or, say, a cardiologist, will he need to complete his residency.

The purpose of the bill is to optimize the learning process: if before interns went to hospitals and worked there for a year under the patronage of professionals, now intensive practice will take place on the basis of clinics at institutes during the last two years of study at the institute. And summer practical classes will begin not from the second year, as before, but from the first.

Thanks to the innovation, the Ministry of Health also plans to solve the problem of a shortage of doctors in state clinics: everyone who entered medical universities in the order of the target recruitment (that is, from a specific medical organization or from the Ministry of Health of a particular region of the country) will have to return the "debt" and work within three years in institutions of the so-called first link, that is, in polyclinics.

Fast, but effective?

“By and large, the abolition of the internship is a good development of events, but on the condition that the new training system will work. After all, the Ministry of Health does not just want to abolish internships, the idea is that students during their five-year study, if we are talking about dentists, and six years, if we are talking about medical doctors, will receive the skills that they previously received in internship.

That is, in principle, everything is logical, because before doctors could not work in their specialty after graduating from the institute. However, there are fears that the amount of skills that were previously given in internships will not be mastered by students. That is, on paper, of course, everything looks fine, but we’ll see how all these innovations will be implemented, ”the vice-rector of the St. Petersburg Institute of Dentistry (SPbINSTOM) comments on the innovations. Maxim Stupin.

Rector of the Nizhny Novgorod State Medical Academy (NizhGMA), Doctor of Medical Sciences Professor Boris Shakhov I am sure that the abolition of the internship will not have a negative impact on the quality of training of Russian doctors, because preparations for this have been carried out in universities since 2012, when the federal state educational standards of the third generation for doctors became known.

“The new Federal State Educational Standard, along with theoretical training in specialties, includes mandatory simulation cycles, after successful completion of which students are allowed to practice in healthcare institutions at various levels.

At the same time, persons studying in the target areas of the healthcare authorities of the constituent entities of the Russian Federation undergo practical training in those healthcare institutions where they will continue their professional activities in the future,” the rector explains.

Rector of the Nizhny Novgorod State Medical Academy (NizhGMA), Doctor of Medical Sciences Professor Boris Shakhov. Photo from nizhgma.ru

In other words, now the practice of a student of a medical university from the very beginning will not be educational, but production, that is, it will be under the control of the teachers of the department where the young specialist is studying. In addition, the internship will be possible only on the basis of clinics where a medical university is “present”. So, no summer hours "sleeveless".

At the end of each practice, students are waiting for an exam, for the failure of which you can be expelled from the university.

A practicing surgeon at one of the Udmurt hospitals (last name not given at the request of the commenter) believes that the abolition of the internship could seriously worsen the quality of medicine in Russia: to serious consequences, and doctors with experience should work there, because no matter how they can make a correct diagnosis and determine whether a person needs hospitalization or not.

The surgeon notes that the internship makes it possible to master the profession of a doctor without the burden of huge responsibility, under the guidance of professionals. “And who will share this responsibility with a doctor who went out to treat people with full responsibility, but without proper practice? Ministers and officials? … I doubt it,” the doctor says anxiously.

What is behind the cancellation of the internship

The majority of specialists agree that working off the budget money invested in the education of students is a quite adequate and fair measure. However, to make this the driving force behind the reform is rather absurd: it is possible to oblige "target" students to work for the state without canceling the internship.

Perhaps the meaning of the law is to divert public attention from the catastrophic gap in the financing of health care in the Russian Federation, in comparison with Western countries, says Associate Professor of the Department of Oncology, Hematology and Radiation Therapy of the Pediatric Faculty of the Russian National Research Medical University. N.I. Pirogov Ruslan Abdullaev.

According to the WHO, US health care spending in 2016 will be over $3.3 trillion (18% of GDP). This is with a population of more than 324 million people. In Russia, with a population of just over 143 million, 479 billion rubles were allocated for healthcare in 2016, that is (at the rate of 76.3) - about 6.3 billion (not trillion!) Dollars.

Associate Professor of the Department of Oncology, Hematology and Radiation Therapy, Faculty of Pediatrics, Russian National Research Medical University. N.I. Pirogova Ruslan Abdullaev.

From 2017, internships will be completely abolished in medical universities. Yesterday's students will practice in the field, in state clinics and hospitals. Beginning physicians will become general practitioners, district therapists and pediatricians. Such changes are dictated by the new educational standard. The innovation is aimed at strengthening the primary link in medical institutions, experts emphasize. However, there is a risk that things may not go as planned. Indeed, having gained some experience, yesterday's graduates will be able to go to private clinics, and state institutions will again be left without the necessary specialists, Primorskaya Gazeta notes.

In the coming year, the system of medical education in Russia will change dramatically. University graduates will be able to go to work after receiving a diploma. Previously, they had to wait at least a year for this. Recall that the internship until last year was considered a mandatory form of postgraduate medical education. Only those who chose residency or graduate school, allowing them to master a narrow specialty, were exempted from it. All the rest had to become interns, that is, to work for a year in a state medical institution under the supervision of a medical practitioner. Only after that, university graduates received a certificate giving the right to practice.

From 2017, upon graduation from a medical university, all graduates will be offered to pass a final certification. The exam will include computer testing and practical tasks. Future dentists, for example, may be asked to fill or extract a tooth.

The test subjects will be evaluated by a special commission. It will include teachers, doctors, representatives of public medical organizations from other regions. Each of the graduates immediately before the exam will be assigned a personal number - no surnames and names. Thus, the human factor, that is, the possibility of rigging the results, is completely excluded.

After successfully passing the exams, young professionals will be able to work in public hospitals and clinics as primary care employees, such as community pediatricians, community therapists or general dentists. Such specialists will also be accepted at the Ambulance Station. Beginning physicians will have the opportunity to develop into a narrow specialist. But for this, as before, you will have to enter the residency. The term of residency training will be increased by next year. For different specialties, it will be from two to five years.

Since earlier students acquired the main practical experience in internships, now much more practical training has appeared in the pre-diploma education of future doctors, teachers say. Over the past few years, each medical university in the country has opened its so-called simulation center especially for such classes. The rooms in it imitate offices in conventional hospitals and clinics. There is all the necessary equipment up to resuscitation. There are also patients. Their roles are "played" by special simulator mannequins. Like living people, they respond to injection pain and other medical interventions. Thus, students have everything to work out the skills necessary in practice to automatism.

It is necessary for a student, for example, to teach intravenous injections, - Rector of the Pacific State University Valentin Shumatov told Primorskaya Gazeta. - How to work them out? On a living person? It is not right. That's what simulation centers are for. There is everything for both emergency medical care and childbirth.

In 2016, beginner dentists and pharmacists have already received certificates for admission to the profession, said Valentin Shumatov. Starting from 2017, graduates of the medical and medical-preventive faculties will also be able to receive accreditation immediately after receiving a diploma.

Each student of a medical university is a potential primary care employee, the rector emphasized. And this means that polyclinics and hospitals in districts where there is a particularly shortage of doctors finally have a real chance to get the right specialist, but we need to try now to get the student interested in coming to a specific institution after graduation.

In Primorye, there are many measures to support beginner doctors, the regional administration specified. There is, for example, the Zemsky Doctor program. Young doctors who agree to work in the outback for at least five years receive a million rubles from the state. For three years 58 people have taken part in the program. In addition, you can learn for yourself a doctor for the target set. For chief physicians, this is a chance to get the specialist they need for the hospital. For a student - the opportunity to study for free and guaranteed employment.

The development of human resources is among the priority tasks facing the regional health care, Pavel Serebryakov, Vice Governor of Primorye, told Primorskaya Gazeta. - And we solve them together with the specialized university.

The introduction of a new educational standard is intended to improve outpatient reception in polyclinics. Often they lack primary specialists. However, it must be understood that there is often a shortage of personnel, not because there are no specialists in principle, but because they are, but they prefer to practice in private clinics. Therefore, along with the improvement of educational standards, it is necessary to remember the improvement of working conditions for doctors in state medical institutions, experts emphasize.

Work in state medical institutions should be competitive compared to private clinics, - Alexander Saversky, president of the All-Russian public organization League of Patient Defenders, told Primorskaya Gazeta. - Otherwise, it may turn out that young specialists will train on ordinary people while they are studying in residency, and after graduation they will go to earn money already in private clinics. And it's not even their fault. Therefore, it is necessary to take measures and finally make the profession of a doctor in a state institution as attractive as possible.

In the summer in St. Petersburg clinics as therapists and pediatricians, yesterday's sixth-year medical students who failed to enter the residency will begin to receive appointments. "Doctor Peter" found out if they are ready to plunge headlong into practical medicine and whether patients can be trusted with them.

Graduates of medical universities in St. Petersburg have passed state exams and are preparing for a three-stage primary accreditation. Those who successfully pass it will receive an accreditation certificate - a document with which you can get a job as a local therapist or pediatrician in a polyclinic from August 1.

Graduates have two options: someone will be able to enroll in residency, this is about 40-45% of the total number of 6th year students, the rest will go to work for us in the primary link, - Valery Kolabutin, chairman of the health committee, said at a meeting of the government of St. Petersburg . According to him, thanks to the innovation from the Ministry of Health, a two-fold increase in young specialists is expected in polyclinics.

Recall that in the midst of state exams, the Ministry of Health issued order No. 212n “On approval of the procedure for admission to study in educational programs of higher education”. Graduates regarded it as an obstacle to admission to residency. On the one hand, they have heard that there will be changes this year, but what they have learned only now. In accordance with the order, to a greater extent, their fate will be determined by a single test within the framework of accreditation. But in addition to testing, achievements for all previous years of study will be taken into account, each of which is evaluated in points. Yesterday's student receives the highest number of points for medical experience acquired during or after training. Anyone who does not get the required number of points, but receives accreditation, a direct road - to the local therapists or pediatricians. Moreover, the number of "free" budget places in universities has been sharply reduced: it is assumed that mainly "targeted" students will study at the state expense, since there is a shortage of "narrow" specialization doctors in the regions. In large cities, in the countryside, on the contrary, therapists are in short supply.

When the order came out, everyone was nervous and worried, it caused a resonance in the student society, - say the graduates of the First Medical School. - Now everyone is calming down, looking for ways out of the situation. Of course, in residency, they mainly go to commerce. But there are few places. The rest are forced to either change their chosen specialty, or become therapists, or leave medicine. And many, probably 25-30%, tend to choose the latter option.

Return a debt

The system proposed by the Ministry of Health of the Russian Federation will be tested for the first time this year. This is an attempt to fill the shortage of doctors in primary care. For a long time, in order to solve this problem, the ministry was asked to return the distribution of graduates of medical universities.

We could not return to the distribution of the Soviet system of medical higher education in its pure form - it would be illegal. Although there was logic in it - if you are studying at public expense, be kind to return the debt to the state, and then do what you want. The same logic works in the current situation, when they decided to make therapists out of graduates, - says Andrey Yaremenko, Vice-Rector for Academic Affairs of the First St. Petersburg Medical University.

Of course, the Ministry of Health does not force graduates into polyclinics. But against the background of the reduction of budget places in residency and changes in the rules for admission to it, the choice becomes obvious for many. Student of the 6th year of the medical faculty of the St. Petersburg State Medical University. Pavlova Elena Artemyeva wanted to continue her studies in residency and become an otorhinolaryngologist. According to the new rules for admission to residency, she has all the advantages for admission - a red diploma, participation in scientific and social activities, experience in a medical organization. However, there are simply no budget places in her specialty according to the general competition in First Honey. All of them are distributed between target users and payers. The girl failed to receive the target referral, despite appeals to medical institutions and authorities:

The fate of those who are not ready to pay for residency has been decided - let's go to work in district therapy, - says Elena Artemyeva, she has already come to terms with her future work in the clinic.

Andrey Yaremenko does not see anything unusual in the fact that the state every year reduces the opportunities for doctors to obtain a narrow specialization:

Every person wants to be unique and get a lot of money. But the state needs doctors of minimum qualification in the maximum number and with a minimum salary. This is an eternal conflict between the individual and the state, and not only in Russia. For example, if you want to become a plastic surgeon in the USA, you need to go through a long and difficult path, invest a lot of money in your education. If you are ready to be a general practitioner (general practitioner), then just write an application and you will immediately be sent to work somewhere in Oklahoma, - the Vice-Rector notes.

Future doctors are most afraid of patients

The trouble is that many schoolchildren, when they choose a profession, go not to medicine, but to a prestigious university. They are excellent students, as a rule, receive diplomas with high scores and go into the industry. Then there is a meeting with the patient and it turns out that there is no dad who can “solve issues” nearby, but there is a patient who was dissatisfied with the quality of treatment and has complaints. A head-on collision with a patient can be very dramatic. Unfortunately, not everyone is ready for it, just as they are not always ready for initial small salaries. Such almost immediately leave health care.

Therefore, the admission of graduates to work in polyclinics raises many questions for the chief therapist of St. Petersburg, Vadim Mazurov.

They will have to immediately plunge into real life and work. It is not yet clear how ready they are for this, - says Vadim Mazurov. - Will the graduate have enough level of training to prescribe instrumental and laboratory examinations? Will he be able to keep documentation, engage in prevention, medical examination? Will he be able to prescribe drug therapy to the patient, choose between the original drug and the generic drug, evaluate possible side effects? Of course, we have clinical recommendations prepared by leading experts, which the general practitioner uses in his work. But when patients with acute respiratory viral infections, coronary heart disease, irritable bowel syndrome come to him within an hour ... You immediately need to have a whole library on the table in order to use the possibilities of clinical recommendations. Such work is a huge burden that requires serious preparation. I'm worried about these kids.

According to Vadim Mazurov, administrations of institutions have not yet encountered such young and inexperienced specialists, so they will also need special attention and patience this year. After all, even after training in residency, a few young specialists came to work in polyclinics, and the staff shortage was solved mainly at the expense of doctors from other regions of the country who already had work experience. According to him, in order for a graduate to feel at least relatively comfortable in a new position, it will take at least two years of work. “These guys will need help, to identify mentors and prepare all the conditions for work,” says Vadim Mazurov.

Graduates themselves count on support:

Of course, all students are worried about whether they will cope with the work. Perhaps, for the first time, we will be in the same office with a more experienced doctor, - says student Elena Artemyeva. - But we still have the skills - the last practice after the fifth year was held in the clinic, the new educational standard prepared us for the work of a local therapist. And for the depth of knowledge there is always a reference manual - it is not forbidden to use it.

At the PSPbGMU im. Pavlova note that they are ready to help their students - for this there is a Center for Interaction with Alumni and the possibility of telemedicine consultations:

They always have the opportunity to talk with a representative of the university if there are any problems. After all, what is the worst thing? When a sick person comes to you, and you don’t understand what’s wrong with him, - says Andrey Yaremenko and asks you to treat the graduates with trust. - Every year, during the flu epidemic, we send 6th year students to work in polyclinics. And we get a lot of grateful feedback, they are both attentive and sensible, they will listen and help.

At the same time, Andrey Yaremenko admits that it is still difficult to call a graduate a full-fledged doctor who can carry out the entire range of diagnostic and therapeutic measures.

It seems to me that there should be some kind of intermediate position between the release of the future doctor from the university and the beginning of his broad professional activity. When a person gets a driver's license in Germany, he must drive for some time in the presence of a more experienced driver. Something similar should be here. At one time there was a wonderful position - a trainee doctor. It was created for doctors who had a break in work for more than 5 years. They received a salary, but worked with a mentor. Only after that did they go full-time. There is also some kind of internship abroad: a young specialist has a mentor, he works in a team, absorbs medical traditions, and this is how he becomes a doctor, - says Andriy Yaremenko.

Forecast: Those who came to medicine “for love” will remain

To find a place in the district clinic, graduates of the First Medical Center can use a specially created database of vacancies. The number of proposals, according to Andrei Yaremenko, is sufficient for everyone. But the problem is that many of the graduates do not need these jobs - they just do not want to go to work as community therapists.

Everyone has a dream. Let's say a student dreamed of becoming the director of an aviation medicine clinic. The first goal on the way to his dream is to get into a clinical residency in extreme medicine. And now he was given a serious barrier in the form of work in a clinic. And if he does not want to work as a local therapist, he will not do it, - Andrey Yaremenko notes.

According to Vadim Mazurov, even those students who go to work in polyclinics, but “not out of love”, but because of hopelessness, are unlikely to stay in primary care for a long time. This threatens polyclinics with staff turnover - young doctors will work for some time and again try to get into residency in their favorite specialty.

- This is another possible problem for the leaders of the institution - they prepared a young specialist, created comfortable conditions for his work. And after a couple of years, the person thanks them and says goodbye. But, on the other hand, there is no other way out of the current situation with a shortage of doctors in polyclinics. Maybe not everyone ends up running away. When I see a young therapist doing an assessment, I usually ask why he works in primary care. Many answer that they just liked it here and wanted to stay, - says Vadim Mazurov.

At the same time, the chief therapist of St. Petersburg asks patients not to be afraid of young doctors:

- I think this will not affect the level of examination and treatment of patients. In the end, it depends not only on the therapist. Narrow specialists will also take part in the treatment. But here, too, there is a snag - the main thing is that a graduate of a medical university does not become a dispatcher, redirecting his patients to other doctors for safety reasons. With this approach, we will not prepare a good specialist.

So far, no one can answer this question with certainty.

So far, it is known for sure that the Ministry of Education of the Russian Federation approved the federal state educational standard, abbreviated as GEF.

Briefly, the main provisions of this standard are that training is carried out only in full-time.

The term of education is 6 years.

The program has a structure consisting of 3 blocks.

Block 1 is disciplines

Block 2 - practices, including research work (R&D). By the way, research is mandatory for obtaining a diploma. It is necessary to have at least one publication in your university before graduation.

Block 3 State final certification, which is currently a mystery.

Since 2017, internships have been completely abolished in medical universities.

Upon graduation, a medical student will have to choose either an expensive residency, or go to work in a polyclinic as a general practitioner, district therapists or pediatricians.

Such changes are dictated by the new educational standard.

It is common knowledge that at present there is an acute shortage of primary care specialists, that is, therapists, for this the state has developed a new educational standard aimed at strengthening primary care.

Thus, yesterday's students after receiving a diploma will be able to immediately go to work. Previously, they had to wait at least a year for this. Let me remind you that until last year an internship was considered a mandatory form of postgraduate medical education. Only those who chose residency or graduate school, allowing them to master a narrow specialty, were exempted from it. All the rest had to become interns, that is, to work for a year in a state medical institution under the supervision of a medical practitioner. Only after that, university graduates received a certificate giving the right to practice.

Now students will receive practice already in the sixth year of study, when they will work under the supervision of their teachers, this is the so-called subordination. It is necessary to emphasize that the majority of experts consider this position not entirely competent, explaining this fact by the fact that it is impossible to “plug” the outpatient link with newcomers in the field of medicine, because almost 80% of all treatment depends on this stage. Such functions should be performed by qualified people who have already completed postgraduate education. The preparatory stage is very important, but it is impossible to work as a doctor immediately after the student's bench, because at the university they give theoretical knowledge, and practice can only be obtained in real working conditions.

Stage 1 and 2 certification of medical students

Since 2017, upon graduation from a medical university, students are required to pass a final certification. The final certification includes stage 1 - computer testing, after stage 2 - a test of practical skills, on simulator mannequins, by the way, each medical university should have a simulation center where this stage is carried out. Based on the experience of last year, we can say that future dentists demonstrate the technique of filling a tooth, or pulling out a tooth, on simulator mannequins.

Stage 3 is the interview.

It is assumed that this stage will be carried out either by answering the questions of an independent commission personally, or the student will sit in front of a computer and, by recording the answer on a webcam, his answer will also be evaluated by an independent commission.

After successfully passing the exams, young specialists can work as therapists in polyclinics or go to residency. The term of residency training lasts from 2 to 5 years. The problem of admission to residency is the high prices for training, and a small number of places. So in past years, there were actually 10-15 state-funded places in each specialty, but now it’s lucky if there is at least one state-funded place. The number of places on a commercial basis has also been reduced. All this is aimed at the fact that young specialists would go to work in the primary link.

Each medical student is a potential primary care employee.

The development of human resources is a priority task in the development of health care. The introduction of a new educational standard is intended to improve outpatient reception in polyclinics. Often they lack primary specialists. However, it must be understood that there is often a shortage of personnel, not because there are no specialists, but because they are, but they prefer to practice in private clinics. Therefore, along with the improvement of educational standards, it is necessary to improve the working conditions for doctors in the state. Uchr.